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Report (69) • 4 SYSTEM RECORD OF COMPLETION This form is to be completed by the system installation contractor at the time of system acceptance and approval. It shall be permitted to modify this form as needed to provide a more complete and/or clear record. Insert N/A in all unused lines. Attach additional sheets, data,or calculations as necessary to provide a complete record. Form Completion Date: /I —1 -t8 Supplemental Pages Attached: 1. PROPERTY INFORMATION Name of property: i3`�-2I 61,J668.6‘ Pkwy 500 179etrdr t ae 447223 Address: /2 e.yri e. 1!pkace .) / Description of property: 5+14fl. p f*'i c e yilee in 5-sib rt/ &u 1 Id 1 15 Name of property representative: / J Address: Phone: Fax: E-mail: 2. INSTALLATION, SERVICE,TESTING,AND MONITORING INFORMATION Installation contractor: Ppin t Moodor Core Address: 5863 L Jcew#.t.J Blvd. Alen LAke OSwelO 1 Q 1e Q7035 Phone: 553-627-0/00 Fax: E-mail: Service organization: _,onv Address: �J Phone: Fax: E-mail: Testing organization: P aS abve Address: Phone: Fax: E-mail: Effective date for test and inspection contract: Monitoring organization: Address: Phone: Fax: E-mail: Account number: Phone line 1: Phone line 2: Means of transmission: Entity to which alarms are retransmitted: Phone: 3. DOCUMENTATION On-site location of the required record documents and site-specific software: rj1'j/ jaCI MQt',q v,,ce 'c,,e_ 4. DESCRIPTION OF SYSTEM OR SERVICE This is a: ❑New system Modification to existing system Permit number: ft ..OI8-000 448 NFPA 72 edition: 7-.014. 4.1 Control Uniti(tst(,'� Manufacturer: 51— Model number: 4.2 Software and Firmware Firmware revision number: 4.3 Alarm Verification 'this system does not incorporate alarm verification. Number of devices subject to alarm verification: Alarm verification set for seconds Copyright©2012 National Fire Protection Association.This form may be copied for individual use other than for resale.It may not be copied for commercial sale or distribution. 1 .1 4 SYSTEM RECORD OF COMPLETION (continued) 5. SYSTEM POWER 5.1 Control Unit E-X4-011 5.1.1 Primary Power Input voltage of control panel: /t-2-o Control panel amps: Overcurrent protection: Type: greeki er Amps: Branch circuit disconnecting means location: Number: 5.1.2 Secondary Power Type of secondary power: Location,if remote from the plant: Calculated capacity of secondary power to drive the system: In standby mode(hours): 7--14 In alarm mode(minutes): 5 5.2 Control Unit ❑ This system does not have power extender panels 121 r/ower extender panels are listed on supplementary sheet A 6. CIRCUITS AND PATHWAYS Pathway Type Dual Media Pathway Separate Pathway Class Survivability Level Signaling Line Device Power Initiating Device B Notification Appliance 15 Other(specify): 7. REMOTE ANNUNCIATORS N/A Type Location 8. INITIATING DEVICES Addressable or Type Quantity Conventional Alarm or Supervisory Sensing Technology r C�-AiS+i f19) -- Manual Pull Stations 2 A ssotbk A iarm L (Eelocal'ed)- Smoke Detectors '32 l��resSable Alarm 19)0 -O Duct Smoke Detectors Heat Detectors Gas Detectors Waterflow Switches Tamper Switches Copyright©2012 National Fire Protection Association.This form may be copied for individual use other than for resale.It may not be copied for commercial sale or distribution. SYSTEM RECORD OF COMPLETION (continued) 9. NOTIFICATION APPLIANCES Type Quantity Description Audible Visible 19-- Wit edbc.k 57 4 Combination Audible and Visible 13 Wkeeloc% NS 5 WL 10. SYSTEM CONTROL FUNCTIONS Type Quantity Hold-Open Door Releasing Devices HVAC Shutdown Fire/Smoke Dampers Door Unlocking Elevator Recall Elevator Shunt Trip 11. INTERCONNECTED SYSTEMS This system does not have interconnected systems. ❑ Interconnected systems are listed on supplementary sheet 12. CERTIFICATION AND APPROVALS 12.1 System Installation Contractor This system as specified herein has been installed according to all NFPA standards cited herein. Signed: 0 Printed name: a-45on Deviti e Date: //-)3— Organization: -)3—Organization: F6,n-l- Mnri ir(ot p. Title: red) Gla� Phone: 503-423-0100 12.2 System Operational Test r This system as specified herein has tested according to all NFPA standards cited herein. /1 (� Signed: Printed name: n-4<or TDe l/l%1L Date: I I'�3�i 0 Organiza ion: 044 Mori 140 Corp. Title: "Tech 4,0 Phone: 50 3-0.7-00 0 12.3 Acceptance Test y� Date and time of acceptance test: /1—/-7 —/g 6:Q©as., Installing contractor representative: Testing contractor representative: Property representative: AHJ representative: Copyright©2012 National Fire Protection Association.This form may be copied for individual use other than for resale.It may not be copied for commercial sale or distribution. NOTIFICATION APPLIANCE POWER PANEL SUPPLEMENTARY RECORD OF COMPLETION This form is a supplement to the System Record of Completion. It includes a list of types and locations of notification appliance power extender panels. This form is to be completed by the system installation contractor at the time of system acceptance and approval. It shall be permitted to modify this form as needed to provide a more complete and/or clear record. Insert N/A in all unused lines. Form Completion Date: I I (1-1-1$ Number of Supplemental Pages Attached: 1. PROPERTY INFORMATION Name of property: Cerl�e d Q Cpitast 2. ) Address: /e3,2:24 5 W (p g-g, pkwy Ft-500 'yi and I Oil T7Z-1-3 2. NOTIFICATION APPLIANCE POWER EXTENDER PANELS CEX4h-1i15) Make and Model Location Area Served Power Source �Si lerl� 61.5114. 51115 FI.5 Elec.//g,4, gfti fir 5 See Main System Record of Completion for additional information,certifications,and approvals. Copyright©2012 National Fire Protection Association.This form may be copied for individual use other than for resale.It may not be copied for commercial sale or distribution.